Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation.

BACKGROUND: Enabling community health workers (CHWs) to treat acute malnutrition improves treatment access and coverage. However, data on the cost and cost-effectiveness of this approach is limited. We aimed to cost the treatment at scale and determine the cost-effectiveness of different levels of supervision and technical support. METHODS: This economic evaluation was part of a prospective nonrandomized community intervention study in 3 districts in Mali examining the impact of different levels of CHW and health center supervision and support on treatment outcomes for children with severe acute malnutrition. Treatment admission and outcome data were extracted from the records of 120 participating health centers and 169 CHW sites. Cost data were collected from accountancy records and through key informant interviews. Results were presented as cost per child treated and cured. Modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change in an equal scale scenario and/or if the supervision had been done by government staff. RESULTS: In the observed scenario, with an unequal number of children, the average cost per child treated was US$203.40 in Bafoulabé where a basic level of supervision and support was provided, US$279.90 in Kayes with a medium level of supervision, and US$253.9 in Kita with the highest level of supervision. Costs per child cured were US$303.90 in Bafoulabé, US$324.90 in Kayes, and US$311.80 in Kita, with overlapping uncertainty ranges. CONCLUSION: Additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision. Further research should aim to better adapt the supervision model and associated tools to the context and investigate where efficiencies can be made in its delivery.

Managing Undernutrition in Pediatric Oncology: A Consensus Statement Developed Using the Delphi Method by the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology.

"Managing Undernutrition in Pediatric Oncology" is a collaborative consensus statement of the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology. The early identification and accurate management of malnutrition in children receiving anticancer treatment are crucial components to integrate into comprehensive medical care. Given the scarcity of high-quality literature on this topic, a consensus statement process was chosen over other approaches, such as guidelines, to provide comprehensive recommendations. Nevertheless, an extensive literature review using the PubMed database was conducted. The following terms, namely pediatric, childhood, cancer, pediatric oncology, malnutrition, undernutrition, refeeding syndrome, nutritional support, and nutrition, were used. The consensus was reached through the Delphi method. Comprehensive recommendations aim to identify malnutrition early in children with cancer and optimize nutritional interventions in this group. The statement underscores the importance of baseline and ongoing assessments of nutritional status and the identification of the risk factors for malnutrition development, and it presents tools that can be used to achieve these goals. This consensus statement establishes a standardized approach to nutritional support, aiming to optimize outcomes in pediatric cancer patients.

Knowledge and practices of traditional management of child malnutrition and associated pathologies in Benin.

BACKGROUND: Child malnutrition is a major public health challenge, affecting millions of children worldwide, with alarming proportions of children under five in Benin. The complexity of managing this condition is increased by its potential association with opportunistic pathologies. An interesting approach arises from the use of medicinal plants, to address child malnutrition and its associated pathologies. This study aimed to document the knowledge and practices of Beninese mothers and traditional practitioners with regard to the use of medicinal plants to treat child malnutrition and associated diseases. METHODS: A total of 844 Beninese mothers and 201 traditional healers were surveyed between March 2022 and August 2023 in the communes of Karimama, Bopa and Za-Kpota in Benin. The respondents' knowledge of child malnutrition and associated pathologies was explored. The ethnobotanical data collected from the subjects concerned the medicinal recipes used to treat child malnutrition, the medicinal plants that make them up and the methods of use. These data were analyzed using ethnobotanical indices such as the Informant Consensus Factor, the frequency of citation of medicinal recipes types and medicinal plants, and the contribution of plants to medicinal recipes. RESULTS: All respondents cited a total of 82 plant species used to treat child malnutrition and associated diseases. These plants were grouped into 37 botanical families, the most common of which were Fabaceae, Malvaceae and Annonaceae. The leaves were the most commonly used part of the plant species identified. The mothers shared 122 medicinal recipes, ranging from recipes based on a single plant to more complex compositions involving five plants. The most notable plants were Moringa oleifera Lam, Phyllanthus amarus Schumach & Thonn, Senna siamea (Lam.) H.S.Irwin & Barneby, Carica papaya L. and Ocimum gratissimum L. Traditional healers provided 52 plants in 71 recipes, with Moringa oleifera featuring prominently in both single-plant and multiplant formulations. CONCLUSION: This study made it possible to constitute a rich base of medicinal recipes used against malnutrition and associated pathologies, with the preponderant involvement of certain plant species. It is therefore necessary to deepen research on these different identified species in order to scientifically assess their potential.

Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) using a modified Delphi technique.

One in three hospitalized children have disease-related malnutrition (DRM) upon admission to hospital, and all children are at risk for further nutritional deterioration during hospital stay; however, systematic approaches to detect DRM in Canada are lacking. To standardise and improve hospital care, the multidisciplinary pediatric working group of the Canadian Malnutrition Taskforce aimed to develop a pediatric, inpatient nutritional care pathway based on available evidence, feasibility of resources, and expert consensus. The working group (n = 13) undertook a total of four meetings: an in-person meeting to draft the pathway based on existing literature and modelled after the Integrated Nutrition Pathway for Acute Care (INPAC) in adults, followed by three online surveys and three rounds of online Delphi consensus meetings to achieve agreement on the draft pathway. In the first Delphi survey, 32 questions were asked, whereas in the second and third rounds 27 and 8 questions were asked, respectively. Consensus was defined as any question/issue in which at least 80% agreed. The modified Delphi process allowed the development of an evidence-informed, consensus-based pathway for inpatients, the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). It includes screening <24 h of admission, assessment with use of Subjective Global Nutritional Assessment (SGNA) <48 h of admission, as well as prevention, and treatment of DRM divided into standard, advanced, and specialized nutrition care plans. Research is necessary to explore feasibility of implementation and evaluate the effectiveness by integrating P-INPAC into clinical practice.

Malnutrition care in hospitalized pediatric inpatients: comparison of perceptions and experiences across two pediatric academic health sciences centres.

Malnutrition affects up to one in three Canadian children admitted to hospital. Awareness among pediatric healthcare providers (HCPs) of the prevalence and impacts of hospitalized malnutrition is critical for optimal management. The purpose of this study was to determine perceptions of malnutrition among pediatric HCP across two major academic health sciences centres, and to determine how the use of a standardized pediatric nutritional screening tool at one institution affects responses. Between 2020 and 2022, 192 HCPs representing nursing, dietetics, medicine, and other allied health were surveyed across McMaster Children's Hospital and The Hospital for Sick Children. 38% of respondents from both centres perceived rates of malnutrition between approximately one in three patients. Perceptions of the need for nutritional screening, assessment, and management were similar between centres. All respondents identified the need for better communication of hospitalized malnutrition status to community providers at discharge, and resource limitations affecting nutritional management of pediatric inpatients. This study represents the largest and most diverse survey of inpatient pediatric HCPs to date. We demonstrate high rates of baseline knowledge of hospital malnutrition, ongoing resource challenges, and the need for a systematic approach to pediatric nutritional management.

Probiotic Supplementation for Promotion of Growth in Undernourished Children: A Systematic Review and Meta-Analysis.

OBJECTIVES: Probiotic supplementation has been proposed as a therapeutic intervention to improve growth outcomes in children with undernutrition. The objective of this review is to synthesize the current evidence on probiotic supplementation for promotion of growth in undernourished children. METHODS: We searched MEDLINE, Cochrane CENTRAL, CINAHL, Embase, LILACS, and Scopus for randomized controlled trials (RCTs) that administered probiotics or eligible comparators to undernourished children below 5 years of age. Our primary outcomes of interest were weight-for-age, height-for-age, and weight-for-height at the longest follow-up points reported. Random-effects meta-analysis was used to calculate standardized mean differences (SMD) for continuous outcomes and risk ratios for dichotomous outcomes. The Grading of Recommendations Assessment, Development and Evaluation criteria were used to assess certainty of the evidence. RESULTS: Nine RCTs with 5295 children in total were included. Durations of treatment ranged from 1 month to 1 year. Pooled analyses from 7 studies showed that probiotics may have little to no effect on weight-for-age (SMD 0.05 standard deviation [SD], 95% CI: -0.04 to 0.13, n = 2115 children; low-certainty evidence) and height-for-age (SMD -0.04 SD, 95% CI: -0.14 to 0.07, n = 1357 children; low-certainty evidence). The evidence was very uncertain about the effect on weight-for-height. CONCLUSIONS: Probiotics may have little to no effect on anthropometry in undernourished children, though there is considerable heterogeneity among the trials reviewed thus far. The interaction between gut microbiota and human nutrition is complex, and further research is needed to determine how the gut microbiome may contribute to undernutrition and how probiotics may affect growth in this vulnerable population.

The Concepts of Women's Empowerment in Child Malnutrition Programs in Luangprabang Province, Lao People's Democratic Republic.

In several developing countries, such as Lao People's Democratic Republic (Lao PDR), the fight against malnutrition is carried out through programs that involve collaboration between internal (national) and external (international) actors. These actors may have different perceptions on what is one of the pillars of these programs: the empowerment of women, especially mothers of young children. Little is known about these differences and the impact of these differences on the empowerment component of collaborative projects and the perception of its impact on the reduction in malnutrition in the country. A multiple case study was performed. Data collection was carried out in Vientiane Capital and Luangprabang province. The data were obtained from (1) documents, (2) semi-structured interviews with representatives of internal and external organizations, and (3) focus group discussions and individual interviews with mothers of children under five years old. Analysis consisted of characterizing the empowerment component of nutrition programs of internal and external organizations, as well as mothers, based on an OXFAM's adapted conceptual framework on women's economic empowerment. The study revealed a common understanding among government and external organizations regarding the significance of promoting women's empowerment for reducing child malnutrition in Lao PDR. However, variations were observed in the interpretation of specific determinants of women's empowerment, specifically in relation to women's autonomy and the role of social capital. The perspective of internal actors includes the political ideology and traditions that make Lao PDR a distinct country. This perspective dominates the nutrition programs conducted under the collaboration of internal and external actors. In Lao PDR, the concept of women's empowerment in nutrition programs conducted through collaboration between internal and external actors and targeting young Lao mothers gives prominence to political and socio-cultural factors.

Barriers to adequate nutrition care for child malnutrition in a low-resource setting: Perspectives of health care providers.

Introduction: Several studies in developing countries found that more need-based training is required for health care providers (HCPs) in child malnutrition management. Methods: An exploratory cross-sectional study was conducted to explore barriers to providing adequate nutrition care as perceived by the healthcare providers (HCPs) in the child malnutrition clinic at a Children's University Hospital in Egypt. Participants were selected using the purposive sampling technique. Five out of seven HCPs in the clinic were included (two male physicians, one female physician, and two female nurses). Qualitative data were collected through in-depth interviews. The interview guide consisted of semi-structured open-ended questions. Quantitative data were the resulting scores from the scoring system used to assess the understandability and actionability of the patient education materials (PEMs) that are available in the clinic. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) for the scoring. Statistical analysis: The thematic content analysis technique was employed for qualitative data. The percent score was generated for the PEM actionability and understandability for quantitative data. Results: Most common child malnutrition conditions encountered by HCPs were nutritional deficiencies. Barriers to the delivery of adequate nutrition care to children were physician-centered: limited nutrition education in the medical school, health system-centered: an insufficient number of HCPs, lack of nutritional supplements, lack of patient education materials (PEMs) that suit the characteristics of the served community, lack of updated standard of practice (SOP) and guidelines, inadequate nutrition training of HCPs, and insufficient time for each patient, and caregivers-centered: the low socioeconomic status and false cultural, nutritional beliefs. Conclusion: There are different barriers to adequate nutrition care for child malnutrition in low-resource healthcare settings. Mainly nutritional deficiencies. Most of the barriers were health system-related in the form of insufficient resources (shortage of workforce; concerning the high caseload, nutritional supplements, and PEMs) and inadequate management of resources (lack of skill-based training, lack of updated SOP and guidelines, and lack of properly designed PEMs that facilitate communication with the target caregivers).

Conceptualising factors impacting nutrition services coverage of treatment for acute malnutrition in children: an application of the Three Delays Model in Niger.

OBJECTIVE: The Three Delays Model is a conceptual model traditionally used to understand contributing factors of maternal mortality. It posits that most barriers to health services utilisation occur in relation to one of three delays: (1) Delay 1: delayed decision to seek care; (2) Delay 2: delayed arrival at health facility and (3) Delay 3: delayed provision of adequate care. We applied this model to understand why a community-based management of acute malnutrition (CMAM) services may have low coverage. DESIGN: We conducted a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) over three phases using mixed methods to estimate programme coverage and barriers to care. In this manuscript, we present findings from fifty-one semi-structured interviews with caregivers and programme staff, as well as seventy-two structured interviews among caregivers only. Recurring themes were organised and interpreted using the Three Delays Model. SETTING: Madaoua, Niger. PARTICIPANTS: Totally, 123 caregivers and CMAM program staff. RESULTS: Overall, eleven barriers to CMAM services were identified in this setting. Five barriers contribute to Delay 1, including lack of knowledge around malnutrition and CMAM services, as well as limited family support, variable screening services and alternative treatment options. High travel costs, far distances, poor roads and competing demands were challenges associated with accessing care (Delay 2). Finally, upon arrival to health facilities, differential caregiver experiences around quality of care contributed to Delay 3. CONCLUSIONS: The Three Delays Model was a useful model to conceptualise the factors associated with CMAM uptake in this context, enabling implementing agencies to address specific barriers through targeted activities.

Understanding malnutrition management through a socioecological lens: Evaluation of a community-based child malnutrition program in rural Uganda.

In Uganda, almost half of children under 5 years old suffer from undernutrition. Undernutrition, a common form of malnutrition in children, encompasses stunting, wasting and underweight. The causes of child undernutrition are complex, suggesting that interventions to tackle malnutrition must be multifaceted. Furthermore, limited access to healthcare for vulnerable populations restricts the potential of hospital-based strategies. Community-based management of acute malnutrition (CMAM), which includes nutritional counselling, ready-to-use therapeutic foods and the outpatient management of malnutrition by caregivers, is recognised as an effective approach for children's recovery. However, evaluations of CMAM programs are largely based on biomedical and behavioural health models, failing to incorporate structural factors that influence malnutrition management. The objective of this evaluation was to understand the factors influencing malnutrition management in a CMAM program in rural Uganda, using the socioecological model to assess the multilevel determinants of outpatient malnutrition management. This evaluation used qualitative methods to identify factors related to caregivers, healthcare providers and societal structures that influence children's outpatient care. Data were collected at a community health clinic in 2019 through observations and interviews with caregivers of malnourished children. We observed 14 caregiver-provider encounters and interviewed 15 caregivers to examine factors hindering outpatient malnutrition management. Data were thematically analysed informed by the socioecological model. Findings showed that caregivers had a limited understanding of malnutrition. Counselling offered to caregivers was inconsistent and insufficient. Poverty and gender inequality limited caregivers' access to healthcare and their ability to care for their children. Factors at the caregiver and healthcare levels interacted with societal factors to shape malnutrition management. Results suggest that CMAM programs would benefit from providing holistic interventions to tackle the structural barriers to children's care. Using a socioecological approach to program evaluation could help move beyond individual determinants to address the social dynamics shaping malnutrition management in low- and middle-income countries.

Evaluation of the child growth monitoring programme in two Zimbabwean provinces.

BACKGROUND:  The child growth monitoring (CGM) programme is an important element of nutrition programmes, and when combined with other child health programmes, it can assist in successful management and control of malnutrition in children. AIM:  This study aimed to assess the extent to which the CGM programme is able to identify instances of childhood malnutrition and how much this contributes towards malnutrition reduction in Zimbabwe. SETTING:  The study was conducted in Manicaland and Matabeleland South provinces of Zimbabwe. The two provinces were purposively selected for having the highest and least proportion of children affected by stunting in the country. METHODS:  The CGM programme in Zimbabwe was evaluated using the logic model to assess the ability of the programme to identify growth faltering and link children to appropriate care. RESULTS:  Records from 60 health facilities were reviewed. Interviews were conducted with 60 nurses, 100 village health workers (VHWs) and 850 caregivers (300 health facility exit interviews, 450 community based). Nearly all (92%) health facilities visited had functional measuring scales. Twelve health facilities (20%) had no functional height board, with five using warped height boards for measuring children's height. Less than a quarter (21%) of the children had complete records for weight for age and height for age. A large proportion of children eligible for admission for the management of moderate (83%) and severe malnutrition (84%) were missed. CONCLUSION:  The CGM programme in Zimbabwe is not well equipped for assessing child height for age and management of children identified with malnutrition, thus failing to timely identify and manage childhood stunting.

Comorbidities of Child Malnutrition in Low- and Medium-Income Countries: A Systematic Review.

The study intended to review the best evidence on prevalence, diagnosis, and treatment outcomes of comorbidities associated with child malnutrition. The study design was a systematic review of quantitative studies. Critical appraisal tools were used to assess the methodological quality of the studies. Data were extracted according to the predetermined data extraction table. Data were further analyzed narratively according to the set study objectives and main concepts. Fifteen studies were eligible to include in the review. All 15 studies reported on the prevalence of 4 child malnutrition-associated comorbidities. Five (n = 5/15) studies reported on length of hospitalization/stay, 10 (n = 10) studies on recovery rate, and 9 (n = 9/15) studies on mortality rate as treatment outcomes of child malnutrition associated comorbidities. The most prevalent child malnutrition associated comorbidities were tuberculosis, pneumonia, gastroenteritis, and anemia. The treatment outcomes identified included the length of hospitalization/stay, recovery rate, and mortality rate. Screening of prevalent comorbidities in children admitted with malnutrition should be standard procedure in practice. More research needs to be done on the diagnosis of under-5 child malnutrition associated comorbidities.

Developing shelf-stable Microbiota Directed Complementary Food (MDCF) prototypes for malnourished children: study protocol for a randomized, single-blinded, clinical study.

BACKGROUND: Childhood undernutrition is a major public health concern that needs special attention to achieve 2025 global nutrition targets. Moderate acute malnutrition (MAM), manifest as wasting (low weight-for-height), affects 33 million children under 5, yet there are currently no global guidelines for its treatment. We recently performed a randomized-controlled clinical study of a microbiota-directed complementary food formulation (MDCF-2) in 12-18-month-old Bangladeshi children with MAM. The results revealed that MDCF-2, freshly prepared each day, produced a significantly greater improvement in ponderal growth than a standard ready-to-use supplementary food (RUSF), an effect that is associated with repair of the disrupted gut microbial community development that occurs in children with MAM. To test the generalizability of these results in acutely malnourished children at other sites, there is a pressing need for a packaged, shelf-stable, organoleptically-acceptable formulation that is bioequivalent to MDCF-2. This report describes the protocol for a clinical study to evaluate candidate formulations designed to meet these criteria. METHODS: A randomized single-blind study will be conducted in 8-12-month-old Bangladeshi children with MAM to compare the efficacy of alternative shelf-stable MDCF prototypes versus the current MDCF-2 formulation that is produced fresh each day. V4-16S rDNA amplicon and shotgun sequencing datasets will be generated from faecal DNA samples collected from each child enrolled in each group prior to, during, and after treatment to determine the abundances of MDCF-2-responsive bacterial taxa. Efficacy will be assessed by quantifying the change in representation of MDCF-2-responsive gut bacterial taxa after 4-weeks of treatment with freshly prepared MDCF-2 compared to their changes in abundance after treatment with the prototype MDCFs. Equivalence will be defined as the absence of a statistically significant difference, after 4-weeks of treatment, in the representation of faecal bacterial taxa associated with the response to MDCF-2 in participants receiving a test MDCF. DISCUSSION: This trial aims to establish acceptability and equivalence with respect to microbiota repair, of scalable, shelf-stable formulations of MDCF-2 in 8-12-month-old Bangladeshi children with moderate acute malnutrition. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05094024). The trial has been registered before starting enrolment on 23 October 2021.

Using traditional healers to treat child malnutrition: a qualitative study of health-seeking behaviour in eastern Ethiopia.

BACKGROUND: Malnutrition among children under five years of age is a major public health issue in many low and middle-income constrained countries. According to WHO, 5.3 million under-five children die every year and about 45% of these deaths are linked to malnutrition. While it is clear that poverty and lack of food are important factors in children's malnutrition, less is known about the ways in which local conceptions of malnutrition affect parents' treatment choices. In Ethiopia, child malnutrition is a severe public health problem and a common cause of child death, and this paper explores the local views of malnutrition and how these shape people's health-seeking behaviour. METHODS: The study was conducted in eastern Ethiopia from December 2017 to January 2019, conducting interviews and focus group discussions to explore different views and treatment options malnutrition. The study used grounded theory because it allows new and unexpected themes to arise from the data. Researchers' assumptions on local terminologies of child malnutrition are also controlled as a principle of ground theory. RESULTS: Child malnutrition was not only perceived to be related to lack of food but was understood in a wider local conceptualization of health and illness. Parents often relied on healers because they are long-standing members of the community, possess indigenous knowledge, and cost less than other options. Because health professionals and the community perceive and speak of health very differently, people often do not seek support from health services. The misalignments between how health professionals and healers diagnose and treat malnourished children have implications on the possibilities to implement change to reduce malnutrition. CONCLUSIONS: Through an exploration of people's own terminology and understandings of what a malnourished child is, as well as the underlying reasons for their illness, this paper explores how people understand malnutrition symptoms and why many tend to rely on healers rather than seeking care from health centres.

Acceptability of Locally Produced Ready to Use Therapeutic Food (RUTF) in Malnourished Children: A Randomized, Double-Blind, Crossover Study.

OBJECTIVE: To compare the acceptability of a locally produced ready-to-use therapeutic food (L-RUTF) with the standard ready-to-use therapeutic food (S-RUTF). METHODS: It was a single-center, randomized, double-blind, two-way crossover study. The participants were 6-59-mo-old children residing in an urban slum, with weight-for-height z score (WHZ) < -2SD. The study had two intervention periods of feeding with two types of RUTF- L-RUTF and S-RUTF-for a period of 24 h, separated by a wash-out period of 7 d. The outcome measures were the acceptability measured as consumption of more than two-thirds of the total calories offered (150 kcal/kg/24 h) and the degree of liking of the food measured by organoleptic evaluation. RESULT: Both types of RUTF did not qualify as acceptable. L-RUTF was preferred over S-RUTF in organoleptic evaluation. CONCLUSION: The study suggests that RUTF products are not suitable for use as a single therapeutic food during nutrition rehabilitation of children with acute malnutrition. The study was registered in the clinical registry of India; Reg. No: CTRI/2018/04/012967.

Clinical and growth outcomes of severely malnourished children following hospital discharge in a South African setting.

BACKGROUND: Data on outcomes of children with severe acute malnutrition (SAM) following treatment are scarce with none described from any upper-middle-income country. This study established mortality, clinical outcomes and anthropometric recovery of children with SAM six months following hospital discharge. METHODS: A prospective cohort study was conducted in children aged 3-59 months enrolled on discharge from two hospitals in the Tshwane district of South Africa between April 2019 and January 2020. The primary outcome was mortality at six months. Secondary outcomes included relapse rates, type(s) and frequency of morbidities experienced and the anthropometric changes in children with SAM following hospital discharge. Standard programmatic support included nutritional supplements. RESULTS: Forty-three children were enrolled with 86% of participants followed up to six months. Only a third of the participants had normal anthropometry at hospital discharge-a quarter still had ongoing SAM. There were no deaths, although four children (9%) were re-hospitalised including two for complicated SAM. Mean weight-for-length z-scores (WLZ) and wasting rates improved at one month but deteriorated by three months. At three months, six children (14%) either had ongoing or relapsed SAM-a SAM incidence rate of 20 per 1000 person-months despite more than half of the participants still receiving nutritional supplements at the time. Risk factors associated with persistent malnutrition at three months included a low WLZ on admission (relative risk [RR] 3.3, 95% confidence interval [95%CI] 1.2-9.2), being discharged from hospital before meeting WHO SAM treatment discharge criteria (RR 5.3, 95%CI 1.3-14.8) or having any illness by three months (RR 8.6, 95%CI 1.3-55.7). CONCLUSION: Post-discharge mortality and morbidity was lower than in other less resourced settings. However, anthropometric recovery was poorer than expected. Modifying discharge criteria, optimising the use of available nutritional supplements and better integration with community-based health and social services may improve outcomes for children with SAM post-hospitalisation.

Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a 3 arms community-based individually randomised controlled trial in decentralised Niger.

BACKGROUND: Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product-ready-to-use therapeutic food-at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < - 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema). METHODS: A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6-59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome. DISCUSSION: This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols. TRIAL REGISTRATION: ClinicalTrials.gov NCT04698070 . Registered on January 6, 2021.